Approach

Management of established oral mucositis (OM) is largely symptomatic, with pain control and oral care as the primary objectives.[22][24][33]​​ Preventive strategies should be instigated during subsequent cancer therapy (if not already initiated) to reduce the incidence and severity of further episodes.

Oral care

Oral care protocols should be initiated in all patients with OM.[22][24]​​​​[27][33]​ These should include standard oral hygiene, such as brushing and flossing, and use of a soft toothbrush to avoid traumatising the oral tissues. Professional irrigation and debridement of tooth surfaces, with atraumatic cleansing of the oral mucosa, may be appropriate. Oral lubrication may be improved by the use of a simple mouth rinse consisting of a half-teaspoon of baking soda in a cup or more of warm water or chamomile several times a day. Other lubricants, such as hydroxyethylcellulose solutions, can also be considered.

Patients with OM require daily oral assessment.[33]

Pain control

For patients with mild to moderate mucositis, simple oral analgesics (e.g., paracetamol, ibuprofen) and the use of topical lidocaine gel or rinse may be adequate for pain control. Other topical agents that can reduce pain include morphine mouthwash. This formulation may need to be compounded by a pharmacist.[45]

For severe ulcerative mucositis, systemic opioid analgesics are commonly needed to achieve adequate pain control. Examples include tramadol, oxycodone, or morphine. In patients undergoing haematopoietic stem cell transplantation (HSCT), patient-controlled analgesia with morphine is recommended as it results in less opioid used per hour and shorter duration of pain.[24][45]​​

Doxepin mouthwash and transdermal fentanyl were considered effective for OM pain control, but the 2020 Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) guideline concluded there was insufficient evidence for or against their use.[22]

Preventive measures during cancer therapy

Preventive measures should be initiated in patients undergoing HSCT, receiving high doses of mucotoxic drugs such as fluorouracil, and in those receiving radiotherapy to the oral cavity.

Palifermin (recombinant keratinocyte growth factor) may be used to decrease the incidence and duration of severe OM in patients with haemotological malignancies receiving high-dose chemotherapy and total body irradiation followed by autologous stem cell transplantation (SCT).[24][46]​ If indicated, palifermin is administered intravenously for 3 consecutive days before and 3 consecutive days after chemoradiation. It may also be considered in patients undergoing allogeneic SCT.[47][48]​ Palifermin may not be available in some countries.

Additionally, palifermin may be beneficial in the prevention of OM in patients receiving radiotherapy to the head and neck along with cisplatin or fluorouracil, and in patients receiving chemotherapy alone for solid and haematological cancers.[49] [ Cochrane Clinical Answers logo ] ​​However, palifermin has not been approved for these indications. 

Use of ice chips and/or ice-cold water held in the mouth before, during, and immediately after chemotherapy infusion is recommended in patients receiving high-dose melphalan as part of a myeloablative regimen for haemotological malignancy, and in patients receiving bolus doses of fluorouracil.[22][23][25]​​ [ Cochrane Clinical Answers logo ]

In patients with metal dental restorations, the use of devices such as a dental guard, cotton roll, or wax to separate the metal from the mucosa can prevent adjacent mucositis due to radiation backscatter.[28]​​

Patients receiving high-dose chemotherapy or chemoradiation before HSCT, and patients receiving head and neck radiotherapy with or without concomitant chemotherapy, may benefit from intra-oral low-level laser therapy to reduce the severity of OM.​[22][24][29]​ The mechanism of action is not well understood, but is thought to be via promotion of healing and an anti-inflammatory effect.[30][31]​​ The 2020 MASCC/ISOO guideline recommends following specific photobiomodulation protocols for optimal response.[22]

An anti-inflammatory mouthwash is helpful in reducing mucositis severity in patients receiving moderate-dose head and neck radiotherapy (up to 50 Gy) with or without concomitant chemotherapy.​[22]​​[32][50]​ However, most therapeutic radiotherapy protocols for head and neck cancer involve doses of 60-70 Gy.

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